Non-pharm interventions for sleep
Exposure to bright light
Structured physical/social activities
Nighttime intervention to Dec noise/light disruption. 
mgmt of insomnia
Don’t start w/persistent sleep complain on sedative hypnotcs (not 1st line). ID other causes first
- If h/p don’t suggest serious underlying cause, mild sx may respond to simple hygiene
- chronic: doesn’t respond to simple sleep hygiene requires another behavior approach
improve sleep hygiene
- maintain regular rising time
- adequate bright light exposure during day
- maintain reg bedtime, unless not sleepy
- dec/eliminate naps not immediately before bed
- don’t use bed for reading/watching TV
- relax mentally before sleeping
- limit alcohol/caffeine
- wind down/maintain period of prep b4 bed
- ctrl nighttime env w/comfy cool temp/quiet/darkness
- try fan/white noise
- wear comfy bed clothes
- if unable to fall asleep w/in 30 mins get oob & do soothing activity (avoid bright light)
CBT for insomnia
combines sleep restriction
stimulus ctrl
cognitive therapy
with or w/o relaxation techniques
sleep hygiene oft also included
sleep meds
most inc fall d/t sedating
short acting used for initiating sleep (more renound/witdrawal syndromes after d/c)
intermediate- acting used for problem w/sleep maintenance (more daytime carryover)
- sedating antipsychotics should’t be used in routine mgmt of insomnia
non prescription sleep products
used by half of OA
melatonin helps w/circadian rhythm disturbance
NOT recommended: sedating antihistamine (anticholiergic s/e), alcohol (interferes w/sleep later at night, other health concers), valerian root/kavakava (herbal, little effectiveness
Impact of visual loss
Visual impairment (<20/40)
Blindness (acuity > 20/200)
65 year old comprehensive eye exam Q1-2y per American academy of ophthalmology
Common eye conditions
Red eye
Ocular swelling or discomfort
Diplopia
Sudden vision loss
Floaters
Ask how’s vision? Check visual acuity.
Check afferent pupillary defect (during swing light test. Pupil less constricted when going from unaffected to affected eye)
Blepharitis
Subconjunctival hemorrhage
Lid scrubs, ophthalmic abx ointment every night at bedtime to eyelids PO doxy
S.H: supportive tx with artificial tears
How atherosclerosis a.k.a. vascular diseases can affect erectile function
Dec intracavernosal blood flow/pressure needed to achieve rigid erection
May cause ischemia of trabecular smooth muscle = fibrosis = venous closure mechanism failure
Peyronie dz: AV fistula causes venous leakage = scarring = abnormal curve in penis
Hormones in ED
Testosterone plays large role in libido
Men with ED and normal test serum concentrations don’t benefit from test supplements may inc libido and vascular risk w/o improving erectile func
ED is a blood flow problem not hormonal
Dyspareunia
From Organic or psych factor or combo
Most common organic cause : atrophic vaginitis due to estrogen deficiency
Libido in women: topical estrogen
Thought to depend on testosterone, rather than estrogen
Can improve vaginal lube/sense of well-being— Has a little effect on libido
Can inc testosterone levels
Caution with women with breast cancer
Ovaries/adrenal are main sources of androgen in women
Flibanserin (Addyi) FDA-approved to tx hypoactive sexual desire disorder (HSDD) in premenopausal women
Mixed urinary incontinence
Both DO and impaired sphincter support/function features inc in both urge and stress
Diagnostic tests for UI
Urinary stress test
Urinalysis to R/O other cause
Post void residual
Urodynamics
Cytology
Bladder Diary/other lab tests
Physical clinical stress test for UI
Bladder should be full
Patient relaxes his perineum/butt
Examiner position to observe or catch any leak after single vigorous cough
Highly sensitive (helpful when negative) for stress incontinence, esp when pt stands
Insensitive if pt cant cooperate/is inhibited or if bladder vol is low
Urinary incontinence lab testing
Only recommended test for all patients (if symptomatic): urinalysis to check for hematuria/glycosuria in diabetics
Dx of UTI requires additional s/s
Do not treat asymptomatic bacteriuria
urge/mixed
incontinence
Urge – sudden, intense urge to void with involuntary leakage (overactive bladder).
Mixed – combination of stress and urge incontinence.
What is bladder training and how is it done?
Teaches voluntary control over urination by delaying voiding until the urge decreases.
Initial toileting every 2 hours (or shorter if needed).
Increase intervals by 30–60 min gradually.
Encourage pelvic floor contractions (Kegel exercises) during urge.
Requires patience, motivation, and adherence (15–20 weeks).
How are pelvic floor (Kegel) exercises performed?
Isolate pelvic muscles only (no abdomen/buttock contraction).
Hold contraction 6–8 seconds.
Repeat 8–12 times per set.
3 sets per day, 3–4 times/week, for 15–20 weeks.
What are antimuscarinic/anticholinergic medications for urinary incontinence?
Reduce bladder overactivity by increasing bladder capacity.
Side effects: Dry mouth, constipation, cavities, cognitive impairment (especially in elderly), avoid in glaucoma, urinary retention, or GI motility disorders.
Examples of antimuscarininc/anticholinergic meds
Oxybutynin – first-line, immediate-release or extended-release, also patch/gel.
Other antimuscarinics – used if oxybutynin fails.
Mirabegron – beta-3 agonist, relaxes detrusor; caution with hypertension.
What drug interactions or contraindications should be noted?
Avoid combining antimuscarinics with cholinesterase inhibitors (risk cognitive worsening).
Monitor for interactions with digoxin, metoprolol, venlafaxine, desipramine, dextromethorphan (especially with mirabegron).
What non-pharmacologic strategies are effective for UI?
Bladder training
Pelvic floor exercises
Pessaries (for stress incontinence) – require hygiene to prevent UTIs
Neuromodulation – posterior tibial nerve stimulation, sacral nerve modulation
Intravesical Botox injections – for refractory cases
